ANN ARBOR, Mich. — Patients undergoing plastic or reconstructive surgery should receive a risk assessment before their procedure to predict whether they’ll develop potentially fatal blood clots in the legs or lungs, according to research at the University of Michigan Medical School. Researchers also found that 1 in 9 patients at highest risk based on that assessment will develop clots if not given clot-preventing medications after surgery.
Published in the November 2010 Journal of the American College of Surgeons, the study evaluated the Caprini Risk Assessment Model, a standard measurement tool used to assess the likelihood a patient will develop dangerous clots in the deep veins of the legs or lungs after surgery. While all patients admitted to U-M for surgery receive a Caprini risk assessment, it is not standard practice among plastic surgeons nationwide.
“Our data demonstrates that the Caprini Risk Assessment Model is a useful and effective tool for predicting how likely a patient is to develop venous thromboembolism (VTE) after plastic surgery,” says Christopher J. Pannucci, M.D., M.S., resident in the U-M Section of Plastic and Reconstructive Surgery and the study’s lead author.
Because past studies have shown that some plastic and reconstructive surgery patients are at high risk for developing clots and only about 50 percent of surgeons administer clot-preventing medications after surgery, Pannucci and fellow researchers sought to specifically validate whether the Caprini model was an effective tool for predicting risk and whether administering clot-preventing medications after surgery can reduce their risk.
“We found that the higher a patient’s Caprini score, the more likely the patient is to develop blood clots after surgery. We also found that patients with the highest scores were at disproportionately greater risk for developing clots if no clot-preventing medications were administered within 60 days after surgery,” Pannucci says.
For the study, researchers reviewed medical record data from 1,126 patients who had plastic or reconstructive surgery and who received no clot-preventing medicines after surgery.
Findings include:
The Caprini Risk Assessment tool is effective in predicting which plastic and reconstructive surgery patients will develop VTE. This study is the first time this theory was tested for plastic and reconstructive surgical patients.
A specific, high-risk group was identified. Patients with a Caprini score greater than 8 are at disproportionately higher risk for developing late VTE; 1 in 9 of these patients can expect to have an event if no clot-preventing medication is given within 60 days after the surgery.
“We used to think people developed blood clots while still on the operating table,” Pannucci says. “But we showed that patients with lower risk scores tend to develop VTEs within two weeks after surgery, while patients with higher risk scores continue to be at risk 20, 40 and even 60 days after their operation.”
The appropriate frequency and duration, and subsequent effectiveness of administering clot-preventing medications after surgery are currently being studied.
Risk Factors: The most common risk factors for developing blood clots after surgery are age, obesity, surgery duration, pregnancy or oral contraceptive use, cancer, personal or family history of clots, and when a person’s blood clots easier than most due to genetically abnormal clotting factors.
Once an injury or surgery occurs, additional risk factors that increase clot risk include multi-system trauma, lower extremity fractures, immobility, multiple operations, need for indwelling central venous catheters, and various post-operative complications like systemic infection.
Effects of VTE: Patients who develop deep vein thrombosis (blood clots deep in the artieries of the legs) are at risk for developing pulmonary embolism. Pulmonary embolism occurs when a deep clot is pushed with the flow of blood toward the heart. This clot can subsequently pass through the heart and obstruct the pulmonary artery — main artery of the lungsresponsible for carrying oxygen-rich blood to the rest of the body – resulting in major heart and lung dysfunction and sometimes death.
Ten percent of patients who develop pulmonary embolism will die within one hour of the onset of symptoms. For patients who survive a PE event, 50 percent suffer strain to the right ventricle of the heart and 5 percent eventually develop chronic pulmonary hypertension.
Patients who develop DVT may suffer damage to the valves in the veins of their legs which can cause venous reflux and post-thrombotic syndrome, a condition where blood pools in the lower extremities causing chronic swelling, tenderness and painful ulcers.
Statistics: In 2008, members of the American Society for Plastic Surgeons performed 1.7 million cosmetic/plastic surgical procedures and 4.9 million reconstructive procedures.
VTE occurs with particularly high frequency after post-bariatric body contouring surgery, including circumferential abdominoplasty (7.7 percent), abdominoplasty (5 percent), and breast or upper body contouring (2.9 percent) and certain types of breast reconstruction (2.2 percent) procedures.
Additional authors: Steven Bailey, M.D., George Dreszer, M.D., Justin Zumsteg, M.D., Reda Jaber, B.S., Jenni Hamill, M.P.H., Keith Hume, M.A., Peter Rubin, M.D., Peter Neligan, M.D., Loree Kallianen, M.D., Ronald Hoxworth, M.D., Andrea Pusic, M.D., M.H.S., Edwin Wilkins, M.D., M.S.
Funding: This study was funded by the Plastic Surgery Educational Foundation.
Reference: Validation of the Caprini Risk Assessment Model in Plastic and Reconstructive Surgery Patients: Journal of the American College of Surgeons – 18 November 2010 (10.1016/j.jamcollsurg.2010.08.018)
http://www.journalacs.org/article/S1072-7515(10)01020-3/abstract
Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike “differentiated” cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
Medical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it. For example, neural cells in the spinal cord, brain, optic nerves, or other parts of the central nervous system that have been injured can be replaced by injected stem cells. Various stem cell therapies are already practiced, a popular one being bone marrow transplants that are used to treat leukemia. In theory and in fact, lifeless cells anywhere in the body, no matter what the cause of the disease or injury, can be replaced with vigorous new cells because of the remarkable plasticity of stem cells. Biomed companies predict that with all of the research activity in stem cell therapy currently being directed toward the technology, a wider range of disease types including cancer, diabetes, spinal cord injury, and even multiple sclerosis will be effectively treated in the future. Recently announced trials are now underway to study both safety and efficacy of autologous stem cell transplantation in MS patients because of promising early results from previous trials.
History
Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner.
There are a number of sources of stem cells, namely, adult cells generally extracted from bone marrow, cord cells, extracted during pregnancy and cryogenically stored, and embryonic cells, extracted from an embryo before the cells start to differentiate. As to source and method of acquiring stem cells, harvesting autologous adult cells entails the least risk and controversy.
Autologous stem cells are obtained from the patient’s own body; and since they are the patient’s own, autologous cells are better than both cord and embryonic sources as they perfectly match the patient’s own DNA, meaning that they will never be rejected by the patient’s immune system. Autologous transplantation is now happening therapeutically at several major sites world-wide and more studies on both safety and efficacy are finally being announced. With so many unrealized expectations of stem cell therapy, results to date have been both significant and hopeful, if taking longer than anticipated.
What’s been the Holdup?
Up until recently, there have been intense ethical debates about stem cells and even the studies that researchers have been allowed to do. This is because research methodology was primarily concerned with embryonic stem cells, which until recently required an aborted fetus as a source of stem cells. The topic became very much a moral dilemma and research was held up for many years in the US and Canada while political debates turned into restrictive legislation. Other countries were not as inflexible and many important research studies have been taking place elsewhere. Thankfully embryonic stem cells no longer have to be used as much more advanced and preferred methods have superseded the older technologies. While the length of time that promising research has been on hold has led many to wonder if stem cell therapy will ever be a reality for many disease types, the disputes have led to a number of important improvements in the medical technology that in the end, have satisfied both sides of the ethical issue.
CCSVI Clinic
CCSVI Clinic has been on the leading edge of MS treatment for the past several years. We are the only group facilitating the treatment of MS patients requiring a 10-day patient aftercare protocol following neck venous angioplasty that includes daily ultrasonography and other significant therapeutic features for the period including follow-up surgeries if indicated. There is a strict safety protocol, the results of which are the subject of an approved IRB study. The goal is to derive best practice standards from the data. With the addition of ASC transplantation, our research group has now preparing application for member status in International Cellular Medicine Society (ICMS), the globally-active non-profit organization dedicated to the improvement of cell-based medical therapies through education of physicians and researchers, patient safety, and creating universal standards. For more information please visit http://www.neurosurgeonindia.org/